Continuing education: speeches by professionals of one Basic Health Unit

Educación permanente: discursos de profesionales de una unidad básica de salud

Abstract

Objective:

To analyze the speeches of health professionals about continuing education in the daily life of a basic health unit.

Method:

Qualitative study developed at a primary health care unit of Belo Horizonte, based on the theory of Agnes Heller's daily life with critical discourse analysis. In-depth interviews with 25 professionals were developed.

Results:

Recycling, updating, institutional responsibility, continuous learning, discomfort and transformation, revealed by vocabulary, interdiscourse, temporality, modality, evaluation and institutional social practice. Professionals blame the institution, but value continuing education for the transformation in work processes and attention to users.

Final considerations and implications for practice:

The discomfort provides action-reflection and changes in the attention to users. Recycle and update relates the professional's adaptation to technological updating, without necessarily producing changes. To expand discussion with professionals about daily potential, for recognition and appreciation of continuing education in daily life, as an instrument of change in social practices.

Keywords:
Education, Continuing; Primary Heath Care; Health Management; Learning

Resumen

Objetivo:

Analizar los discursos de profesionales de salud acerca de la Educación Permanente en el cotidiano de una unidad básica de salud.

Método:

Cualitativo. Escenario: una unidad básica de Belo Horizonte. Referencial: cotidiano de Agnes Heller con análisis crítica de discurso. Entrevistas en profundidad con 25 profesionales.

Resultados:

Reciclaje, actualización, responsabilidad institucional, aprendizaje continuo, desacomodación y transformación, reveladas por el vocabulario, interdiscurso, temporalidad, modalidad, evaluación y práctica social institucional. Responsabilizan a la institución, pero valoran la educación permanente para la transformación en los procesos de trabajo y atención a los usuarios.

Consideraciones finales e Implicaciones para la práctica:

La desacomodación proporciona acción-reflexión y cambios en la atención a los usuarios. Reciclar y actualizar relaciona readecuación del profesional a la actualización tecnológica, sin necesariamente provocar cambios. Ampliar discusión sobre potencia de lo cotidiano, para reconocimiento y valorización de la Educación Permanente como instrumento de cambio en las prácticas sociales.

Palabras clave:
Educación Permanente; Atención Primaria a la Salud; Gestión en Salud; Aprendizaje

Resumo

Objetivo:

Analisar os discursos dos profissionais de saúde acerca da Educação Permanente no cotidiano de uma unidade básica de saúde.

Método:

Qualitativo. Cenário: uma unidade básica de Belo Horizonte. Referencial: cotidiano de Agnes Heller com análise crítica de discurso. Entrevistas em profundidade com 25 profissionais.

Resultados:

Reciclagem, atualização, responsabilidade institucional, aprendizado contínuo, desacomodação e transformação, reveladas pelo vocabulário, interdiscurso, temporalidade, modalidade, avaliação e prática social institucional. Responsabilizam a instituição, mas valorizam a educação permanente para a transformação nos processos de trabalho e atenção aos usuários.

Considerações finais e Implicações para a prática:

A desacomodação proporciona ação-reflexão e mudanças na atenção aos usuários. Reciclar e atualizar relaciona readequação do profissional à atualização tecnológica, sem necessariamente provocar mudanças. Ampliar discussão com os profissionais sobre potência do cotidiano, para reconhecimento e valorização da educação permanente no cotidiano, como instrumento de mudança nas práticas sociais.

Palavras-chave:
Educação Permanente; Atenção Primária à Saúde; Gestão em Saúde; Aprendizagem

INTRODUCTION

Continuing education (PE) has been adopted in the health sector with the purpose of rethinking methodologies and policies that allow changes in behaviors and practices, through the integration and structuring of knowledge, resulting in new ways of thinking. It is understood that PE is a social phenomenon, multi-professional, collaborative and collective necessary for the development of health work.¹ The historical construction, from 1980, the discussion of the PE turned to the work process with appreciation of the experiences and practices of the subjects in action, stimulating the problematization and the creative capacity, for the collective analysis about the real problems, in search of the transformation of the health practices and the construction of new knowledge.

In Brazil, the Continuing education in Health presents itself as a proposal of strategic action of the Unified Health System (UHS) for the development of the health professionals in the services. In this area, the learning process is based on the reality lived at work and has potential for the transformation of health practices.

The National Policy of Continuing education in Health, established in 2004, is based on the assumption of learning as a daily exercise for the identification not only of difficulties and obstacles, but also of the possibilities of effective construction of qualified care, considering Continuing education in Health, incorporated into their daily lives, the learning and the teaching.² In 2007, new guidelines and strategies were introduced, taking into account regional specificities, training and development needs for health work.³

Despite the normative apparatus, several challenges to understanding and action on lifelong education are identified. There is a conceptual difficulty in the understanding of lifelong education, such as the vision of educational action not imbricated in everyday praxis, restricted to established formal moments, with prioritization of technical issues.⁴

Other challenges are related to the implementation of teaching-learning processes not supported by critical-reflexive and participatory actions, as well as the non-recognition of the professionals' potential in their daily actions, which inform and produce PE. In the face of this, it is observed that PE has been happening in daily life in different ways and initiatives, taking various forms, from the most traditional modes, in formal teaching-learning actions, to those configured in other non-traditional formats, in daily actions that produce knowledge and can induce change.

It is known that subjects must be involved in these changes. Teams have moved to solve problems, but they seem not yet aware of the unique dimension of their action for this process, necessitating investments in PE processes. It is believed that PE occurs daily in its different forms of learning production, formal and non-formal, contributing to the change of the subjects in health services, and can have repercussions in the care model. Thus, by problematizing health care, they create a potent field for transforming the practice, which occurs more or less intensely, according to the different structures established in the services. However, the difficulties related to the conception of what is PE provide the non-recognition and appreciation of its event in the daily life.

For the study, the concept of education is considered as the one that must consider the man capable of changing the world with his intelligence and his action, who acts in a critical and active way in the process of transformation of society and work.⁵ Therefore, education would be a social process, a human action-reflection movement for the transformation of reality. With this, PE, in the daily life of the health services, must turn to the subjects, in their interpretations of the norms against the lived reality that, in the majority, subjectivize them and produce daily life in the direction or not of overcoming it.

This article presents partial results of a study that seeks to analyze continuing education as a device for changing the model of care in the daily life of a Basic Health Unit (BHU). It is a qualitative research anchored in the theoretical reference on the quotidian, in the aspect expressed by Agnes Heller.

In this context, to know how the PE has made possible the transformation of the care model, as well as to know the movements in the daily routine of primary health care in the basic health unit, it was necessary to inquire about the discourses present in the daily life of health professionals. Thus, it is questioned in this study: Which discourses of continuing education are present in the daily life of professionals in a basic health unit? How do these discourses relate to changing practice and health care models? The objective was to analyze the speeches of health professionals about Continuing education in the daily life of a basic health unit.

METHOD

This is a qualitative study anchored in Agnes Heller's quotidian referential. This author affirms that daily life is the life of every man who is on the stage of events and of the development of life, whose first data are the daily attitudes of the human being. With this, the understanding of the historical and economic development of society is combined with the consideration of the heterogeneity of human actions and reactions in the everyday sphere. The man participates in life with all aspects of his individuality, of his personality. In it, he places all his senses, all his intellectual capacities, his manipulative abilities, his feelings, passions, ideas, and ideologies, even being conditioned by the society to which he belongs.⁶

The man undergoes conditioning by society to ensure his survival in his environment. However, from the moment he is confronted with new experiences that flee from the everyday and its repetitions, he can experience an enlargement of his gaze, given by the awareness, in an enlarged sphere beyond the world that surrounds him. In this way, it broadens his discourse, his practices and social relations.⁶

The same author, for whom daily life appears as the basis of all spontaneous reactions of man in his social environment, affirms that man must move towards the search for freedom and autonomy in processes of subjectivism of reality, surpassing daily life.⁶ A freedom and autonomy in the everyday world, are possibilities for the subject to interpret the content of social norms, to reject some, to accept others, or to prefer other values, since everyday life is full of alternatives and choices.

In this sense, the discursive practice, the text, and the social practice, integrated among themselves, are products of social relations and relations of power. Thus, discursive practices regulate social identities in respect to values, ideologies, and beliefs in the lived quotidian.⁷

For the analysis of the empirical data, the referential of the critical discourse analysis was adopted in the English language. This framework is based on a three-dimensional model to understand discursive practice, text, and practice in an analytical framework for the analysis of discursive events. It is argued that the analysis of textual properties should be integrated both with the analysis of social relations and opaque relations of power, and with the idea that discursive practices are regulators of social identities and are emerging spaces of values, ideologies, and beliefs.⁷

The study scenario was a basic health unit located in the city of Belo Horizonte. The capture of reality happened, initially, by peripheral participant observation. In-depth interviews were conducted with 25 professionals from the unit, who had more than one year of primary care and the Family Health Strategy, regardless of the professional category (seven community health agents - CHA, one nurse, four doctors, six nursing technicians, a dentist, an oral health technician, an oral health assistant, a social worker, an occupational therapist, a zoonosis agent, and the unit manager). The intention was to include all the professionals of the unit, but there were refusals of four CHA, a nursing technician and a nurse. All professionals interviewed signed the Term of Free and Informed Commitment (TFIC).

The interviews were carried out at the health unit from November 1^st, 2017 to February 8^th, 2018 and focused on the participants' understanding of permanent health education, its occurrence in daily life, challenges, and difficulties. The recording of interviews totaled 21 hours, with an average duration of 58 minutes for each interview.

The material was transcribed in full and coded, with alphanumeric code composed of the letter T and numbers for the interview sequence, all considered as health workers. The interviews were prepared for discourse analysis, using specific symbologism with graphic elements to indicate, for example, speech interruption, truncations, incomprehension of words,⁸ among others.

For the organization of the empirical data, the following path was established: an exhaustive reading of the interviews, searching in the speeches for the concept of PE as enunciated by the participants. Next, the keywords and other elements that corresponded to the textual dimension of the discourse were mapped. From this movement, the categories related to discursive practice and social practice were identified, conforming the three-dimensional analysis proposed by Fairclough, being the categories of analysis informed in the results of this study: vocabulary, temporality, institutional social practice, evaluation, modality, and interdiscursivity.

The vocabulary refers to the dimension of the use of the language that involves processes of production, distribution, and consumption of the texts. Interdiscursivity refers to the articulation of discourses and the way they are articulated. Temporality refers to the temporal relationship involved in the social context, which represents certain actions and modes of interaction, evidencing the transition of practices between time frames. Social practice places discourse in a perspective of power as hegemony and ideology, using metaphors that identify how the world is perceived and how we behave in it and relate to each other, according to physical and cultural experience. By modality is meant the judgment about the probabilities or compulsions involved, with intermediate choices, with semantic traits that mark opposing poles, with intermediate possibilities of choices, being able to be deontic modalities (involving obligation) or epistemic (involving commitment to the truth). The assessment includes evaluative statements, with value judgments and value presumptions of what is desirable or undesirable.⁷

The project, of which this article is one of the products, was submitted to the Research Ethics Committee of the Federal University of Minas Gerais, CAAE number 62614916.0.3001.510, with the opinion of the participating institution, number 1.952.027. At all stages of the study, the guidelines of Resolution 466/2012 were met.

RESULTS

When asked about what is continuing education, the interviewees used a series of words: courses; recycling; training; continuing education; preparation; improvement; and updating. There are also expressions that refer to work-oriented education, learning and continuous process.

Professionals associate continuing education with recycling, in a process that must happen continuously. Thus, the discourse is textually marked by adverbial and temporal modes that always express continuity (recycling).

(01) I think that continuing education, continuing education, it is important to retrain the professional ... the professional always being able to attend to the best [...] I think it's the key to success of the service, right? Continuing education is everything, if one does not have a continuing education, one deteriorates in relationships with another, in work relations, and one becomes a product, right, in quotes, obsolete. [...] Today or yesterday I was arguing with the guy that, for example... today he is doing a course of recycling concerning rabies, the antirabies vaccine, which changed the protocol (T12).

(02) Well, I understand that continuing education ... [stops and thinks] it's like a recycling, right? You learned there in school and here you learn in practice, but you have to keep recycling yourself, getting better, right? And adapting to the new teachings, the new things that arrive that, in fact, for me still have a little difficulty, may even be as they say, stay... think... of being afraid of not conforming to the new things that are coming (T21).

(03) It changes because it recycles, right? Take people out of the comfort zone, when you think it's okay, that you've learned everything, in the same course, we redo some concepts to improve the work of the collective good (T01).

In the excerpt 01, the professional represents continuing education through the metaphor key of success. In attributing the condition of everything, it affirms that the professional is indispensable in the relations established in the work.

The interviewers use as subjects in the affirmations we to position the team in the continuing education. This finding demonstrates the recognition of individuals who are stripped of individuality, marking a collective discourse, of an extended subject, giving the notion of a set in the labor relations.

The discommoding is an element that causes the need for PE, presented in the speech by the metaphor takes people out of the comfort zone (excerpt 03). In the excerpt 04, T22 also understands the PE as a call for leaving the automatic mode, causing the professional to watch for the changes that happen in the service.

(04) Look, during the service, sometimes we go into an automatic state, to answering things in the automatic. And I see it like this, continuing education as a call for LEAVING THE AUTOMATIC MODE, right? Often, concepts change, but sometimes we are SO IN THE AUTOMATIC, that we have a notion of that, but we do not know, sometimes, how to put it, right? (T22).

The use of the metaphor automatic mode evokes actions in a work process that are independent of the conscious will. In this context, PE is a device that can trigger non-automatic modes, in a process that depends on the conscience for the professional performance. In this sense, dismantling is a condition to open up to the new and to recycle. The categorical statement SO IN THE AUTOMATIC MODE is followed by the explanation that, despite the knowledge, it ends up using the convenience, using the repetitions of attitudes that are accepted socially by the team and the users.

Accommodation generates discouragement, which gradually leads to a return to daily life without prospects, which is referred to in the loss of grace, in the excerpt 05. Temporarily it indicates a process of gradual loss, we lose, of the update and strength at work. The PE, identified in a value evaluation as important for the reactivation of the mood, is evidenced with the metaphor, gas.

(05) We're getting a bit discouraged. So, the professional education... permanent, I think it brings us, besides the update, the gas... that, sometimes, we lose a little bit, losing the grace. So, I think it's superimportant (T09).

The continuing education is also compared with the formal learning, realized through courses that provide improvement and adequacy to the new things (excerpt 06). The noun things, in the daily life of BHU, can refer to protocols, procedures, new guidelines of local, district and municipal management and the demands of the service in general. So, there is a bit of things that need updating.

(06) The nurse accompanying us daily... passing in the case, new things... and not only the nurse does... in the case we also have to update ourselves... the same as now we are having, in the case of the vaccine, there is this course of vaccination going on that was even with this course is that we have seen so much of thing that we have done and that is not anymore... [stops talking, makes a gesture with the shoulders indicating that it is no longer practiced] (P17)

(07) Continuing education? It's ... [stares at me] we're always updating the protocols, vaccine, pharmacy... [stops and thinks] it's always having a course for us to update, so the care won't, the care won't stay out of date (P18).

The results indicate that it is frequent among professionals to refer to PE as training, updates and improvement, through courses of different extents. In this sense, the speakers highlight the courses as an updating tool, temporalizing their offer, which needs to be continuous, thinking about the evolution of knowledge and ways of doing. Modify the speech when affirming the obligation of updating, it has to be updated.

The daily life is marked by repetitions that reproduce a regularity of actions in the services. In this routine, the courses fulfill the function of breaking monotonous as they allow for updates.

(08) It's this change... Because any course you take, graduated, so cute... but changes. Next year there will be another thing new in Medicine, as well as for dentist, as well as for Nursing... So you have to follow up... that you have to evolve, you have to follow, keep adjusting, right? The same with curatives, every day a novelty, a different coverage, a different way of conducing. So if you do not have this tracking you get out of date with information (T17).

(09) When you ask this at once, we have to think a little... Look, what I understand, continuing education, is an update with professionals according to the demand that we are seeing in the service. So, the difficulties, the problems, to empower the professionals to improve that service (T15).

It is added that the vocabulary and verbal tenses, in the statements of the participants, inform temporality in the indications of continuity, as well as also inform modality in the positive and categorical affirmations (you have to follow, you have to evolve), demonstrating the concern with the monitoring of the new knowledge and new technologies applicable in the health service.

(10) [...] and always the training courses within our area of ​​coverage. [...] It is all that which is passed on to us, we are careful to be practicing it there daily (T01).

(11) I'm always doing these courses because I think it's also another way to adjust. And I have passed on to my colleagues, the other day I passed the link to my fellow doctors here, because I see that many people sometimes do not know about the courses and then don't take them. So, I showed it to my colleagues and said: "People, access this link, the courses are very good, adequate with the norms of the Ministry, with the technical norms, with the best of... dissemination, courses are always recycled, in terms of the subject, that is, always the new subject, right? According to the literature". So, I think it's how we train ourselves (T12).

Other discourses reveal the extent of access to professional knowledge by representing PE in the "theoretical" dimension that shapes hegemonic thinking about educational processes. Thus, being in practice by practice has less value in discourse, it is necessary to "theorize" to qualify the practice, continuously (always improving).

(12) Look, I think continuing education, when I think of continuing education, I think of you aligning theory with practice, right? I think the theory is a driver for you to work, right? I think it's important for you to be in touch with the theory. So, I think continuing education is you, from time to time, to have this contact, this reflection, right? It's adding to your practice too, right? For us not to be just in practice by practice itself, for us to have a reflection, a moment to work on the theoretical question. [...] We commented here that in the beginning there was a lot, a lot of course and it was not called continuing education. Suddenly, they changed their name to continuing education, and then we could not do more than two a year. So, by the way, even that they have lessened. Yes, they restricted (T25).

It is important to emphasize that the participants indicate that the PE offer is of institutional responsibility, marking their speeches by evaluations that this offer has been restricted or has not happened as expected, sequentially, attributing to this the discouragement in the daily work.

(13) [...] I think that talking about continuing education had to be like, sequential. One course has gone, another begins. Don't leave that space between one and the other, because this even discourages us. So, if it had a rotation, if it were continuous, permanent... (T17).

In a judgmental tone of the institution, professionals affirm that they do not have a protected schedule in the PE agenda, as well as explain the drop in the provision of devices such as teleconferencing and courses, timing the comparison of before and after, referring to the current management. The negative valuative evaluation when using the truly PE expression, excerpt 15, asks whether such a process has occurred in the daily life of BHU.

(14) [...] being in an institution like PBH, through a program of the institution that aims at continuing education, such as courses, updates, symposiums, congresses [...] and we do not have a protected schedule anymore in our agendas with continuing education [makes gestures that inform negativity and a facial expression of criticism], this is a failure in the current management of the PBH because in the previous management we had guaranteed the nuclei, the PEN, continuing education nuclei... we had the study centers, we had biweekly meetings, monthly meetings for us... there was a protected schedule in the agenda for continuing education and today we don't have (T13).

(15) Well, people know that there is self-learning. There is even after the person has graduated, gotten a degree, they can thus, autodidactically go forward. However, if it had been linked to a truly continuing education program, I believe that the steps would be faster and more in the necessary direction linked to the needs of the job. I think that continuing education, maybe this way, it sins because, often, its stays out of the work schedule, right? (T14).

(16) [...] Now the issue of continuing education, even courses, that's what... [she gestures with her hands, indicating that the PE is out of her. She looks at me with a facial expression of one who wants approval. I make a gesture with my shoulder, I do not know] she continues: okay! The Municipal Administration owes us. It's been a long time since we had a course, you know? Last year we had no more teleconference, which we used to have every month, a topic was discussed. And we as a professional, too, like what you do? The city makes a limited offer to a certain type of procedure, you end up already half discouraged to do... I have already done many courses in my life. I have not known how many hours of college post course. Now there's a lot of time I do not do (T09).

The participants also revealed that the offer is fragmented by professional procedures or categories (excerpt 17, 18 and 19), requiring an analysis of the need to protect the multi-professional and interdisciplinary nature of PE. It is added that they interfere with learning in the daily practice of work.

(17) [...] so, we have some courses that the city hall offers, right? So, in this whole period I'm here, I did a course, which was anti-rabies update. So, I guess at least for medical part, right? I know I had several other vaccine room proposals, curative room, hosting, several other parts, but at least of the attending physicians I found to be few, right? For the demand that we have and the much of update even if it happens... change of protocol, of everything thus, then I think it is still little for what happens. It turns out that we learn in practice, we look for the knowledge as well. When something goes wrong, they send us back and then we will know what different is happening (T15).

(18) [...] I just think you have to add, you know? I think continuing education... the UHS could do even more, work more on it with several professionals. I see it has some categories, there are not others... I think this is a way to encourage the professional to always be engaged in the service. I think that you can never learn too much, so we always need to improve ourselves... (T24).

(19) [...] This is one of the things that we have put [...] that we miss very much, because all the professionals, at some moment, they are called for some qualification (T11).

In the excerpt 19 it is possible to identify, through the metaphor you can never learn too much, a belief that knowledge is infinite, referring to the offer of courses by the institution as a way to stimulate the professional, also putting in evidence, a condition of professional engagement in the service.

Engagement refers to the notion of PE in the daily life of the health service. Interdiscursively, the professionals affirm that the work is the central object of the PE, referring to the discursive practices produced in the health field in the last decade. PAHO's interdiscourse is related to the meaning of the PE to enable transformations of professional practices in the daily life of health services, based on the reality of work, meaning an ideology of everyday praxis.

Thus, PE is not a course, it is not a teleconference, it is not a lecture, but it is something that happens at work, through work and for work. On the other hand, by valuing courses and training the participants attribute to the institution the responsibility for the institutionalized offering of continuing education in an interdiscourse of the Ministry of Health and of the Municipal Administration.

(20) I think the spirit of continuing education is that it should happen during working hours. And it was tied to the needs of the job. Sometimes we find people who go on taking courses around, right? I don't know, right? He chooses to take a course, something stratospheric and goes and does it. This is not continuing education. Continuing education is for the right job! For the needs of the job. [...] So, showing, thus, the gaps of continuing education. Continuing education, for me, like this, it's not teleconsulting, right? It's not a lecture, right? All this I find very interesting. A library, for example, I usually watch, I really like teleconsultories. I watch at home, here there is no way to, right? But this is not continuing education. Continuing education is one that allows, according to the demand, according to the need, right, at that moment I have the condition to access and have an answer, for a better attitude (T14).

Other professionals reveal pragmatism and spontaneity, associating the PE with what one learns to put into practice at work.

(21) I understand continuing education... the courses that we do in this period of work, focused on work... that we can bring information to the patients, to the unit... because permanent is knowledge, I believe, right? Not if that's what you do... that's right. I understand it as if it were this, both by the Municipal Administration giving the courses, and by us. So I understand this as continuing education, within the service. Maybe it is more linked to the service, own service, being better directed... (T24).

(22) It's a very new thing, a lot of learning, so something new is always coming up. So I think... we still have that fear of, of those courses that we are doing that are saying that we will have to learn to gauge pressure, some things that we think are more of a technician. Nursing, right? But I see [...] everything as learning. Whatever comes to me to be learned, to me it's a bonus (T07).

(23) Look, I... what I see like this... is that continuing education, like this, needs to happen better, you know? That sometimes we're put in the area and do not have that monitoring like that, you know? Sometimes it puts in the vaccine that is a very complex sector, that we need information, need to know much detail and when you go to see you are already doing several things for a long time and that it has already been a long time that it has already expired... that it's not like that anymore, so it's... [...] when we have any doubts, anything, sometimes we have to call in the immunization, in the case of the vaccine, right? So, I think, that we are little... How can I talk? Poorly assisted, you know? (T22).

(24) So, I believe that continuing education is a very important thing for us, especially in our area in the biosafety matter, right? Because sometimes concepts change and norms change, and we do not always have access to that information. In the old days, in the city hall, every year end we had the workshops, right? [...]. We get so caught up in what we learned many years ago. So I think it would be important that this issue of people always be doing an improvement course, right? It's very important, right? Mainly in this area of ​​biosafety (T22).

The metaphor to me it's a bonus, excerpt 22, refers to the new learning that accumulates. Similarly, at 23 the participant reports on the need for continuous updating so that what is known is not outdated and useful to the present day. The new seems to be the fuel of PE in everyday life, which provides an opportunity for learning, establishing a movement of continuity.

(25) I think we always have to be open to new options, new experiences, expectations... I live a lot in expectations... and always want a new one. And the experiences too... I always want a new one ... so we have to be ready for it. And whatever, that has to do with today's thing, current ... what comes tomorrow we always have to seek the best... Permanence cannot exist... I think permanence is to remain today... tomorrow... is to think about the future. That's what I think is continuing education... we always get educated... (T03).

(26) [...] Let me think... I think we are constantly learning. We see new things every day. We... we do not have a routine like that... we always have something new and we need that. And often, we do not only study with those who give... class, the city hall provides the protocols for us. Constantly have to consult the protocol, to study, this for me is an education that is constantly done. Protocol change, you have to check. So I think it has several activities that is constant (T10).

In 27 and 28, the participants mention the inseparable relationship between work and learning: while working, one learns.

(27) Well, continuing education means that, as the name says, throughout the time that you are working you are also learning through, an individual's professional initiative, to update yourself, to study a case that you cannot solve, update itself through various update programs that exist, new protocols, [...] continuing education would be that, you are working and you are also learning (T13).

(28) [...] It is a system of continuous learning that we have, in relation to our work. And (?), on top of our activities and continuous [...] It's that we always are, like, we are always learning (T01).

It was possible to identify the temporal relation of continuity that is built on the PE, like that which is continuously processed, throughout life, to the point of naturalizing it in the daily work, making people better.

(29) Obviously, then, what will we think, if we live in the environment of continuing education, right? We find a professional at the beginning of his career and then we meet him, I do not know how much time, necessarily, this professional has to be much better. Right? [...] By human nature itself, if we all always want to improve, this is the natural movement of everything, right? [...] (T14).

(30) [...] Well, I think that continuing education is the continuity of a process of actually empowering and changing people's habits in the face of that theme. It is... and I think, fundamentally, that it is of fundamental importance that this continuing education be in fact permanent, so that people do not have any loss in the service, in the processes. Mainly, of assistance, organization of flow, right, well... in the various subjects that we attend and... have the possibilities of approach (T11).

Getting in touch with the new is what provides experiences and maturity for action in the quotidian, being attributed to the PE a dimension that extrapolates the professional education with the purpose of forming aptitudes for the productive and social life.

DISCUSSION

The findings indicate that the discourses on PE go through the representation of recycling, updating knowledge, discommoding and transformation of practice and learning for/throughout life. To reveal these representations, the discourse is marked by the categories of vocabulary, interdiscourse, temporality, ideology and modality.

Recycling composes the vocabulary universe of health professionals when reporting PE. Considers that recycling, as used in the area of ​​material reprocessing, involves the reuse of a useful part of the waste and reintroduction in the production cycle, and can also be considered as the reprocessing of something when it is necessary to improve its properties or improve their income.⁹ Thus, retraining for health professionals, refers to the complementary training given to a professional to enable him to adapt to technological and scientific innovations.

Now, a product is something that results from a certain work process, such as that which can be measured according to certain quality specifications and references. As stated by health professionals, recycling turns to the understanding that the professional needs to be recuperated in order to recover their functionality and become useful in the health productive chain.

The adoption of the term recycling in the field of professional health education goes back to concepts that were in force in the 1950s and 1960s in face of the developmental model in Brazil, which also adopted the international discourse, inspired by Theodore W. Schultz's theory of human capital, in the late 1950s. Thus, in a pragmatic view, professionals were resources that should be reprocessed, recovered or improved according to the technical need.¹⁰

This way of thinking guides the economic planning proposed by the strategy of the Economic Commission for Latin America and the Caribbean (ECLAC), which begins to advocate integrated development as an instrument to overcome underdevelopment, influencing Brazilian educational policy, especially from the second half of the year 1960. Consequently, in the professional field the technical conception begins to reign, reflecting in courses of recycling and updating in line with the hegemonic ideology that reinforces health as a productive sector.¹⁰

It is added that, in Brazil, the 1960s were marked by military dictatorship, in the repression of democratic practices. In this context, professional education was directed towards adapting to the productive process, whose investments aimed at development policy with a strong economic bias. In this scenario, it was necessary to produce competitive professionals and easily adaptable to the productive machine. For this, the technical approach was the orientation of teaching models, in a pragmatic and instrumentalist view of reality.¹⁰

In the following two decades, a new movement was opposed to the conception of adaptation of education, especially in the 1980s, in a process of discussion and construction of a new meaning, which positions the education of health professionals towards work. This concept is reinforced by PAHO in Latin America, such as education focused on health work. In this area, the education of professionals aimed at learning at work, for the work and to the work.¹⁰

From then on, PAHO's influence began to be explored in an instrumentalization for the work in preparing health workers for the health area. For example, the Ministry of Health adopted this term when it presented, in 1996, at the X National Health Conference, a plan for training, preparation, continuing education and retraining of human resources in health. At that time, the continuing education returned to the qualification of the professionals as form of technical update with focus in the work.¹¹

In the current scope of health, it is necessary to develop competencies to meet the demand for the incorporation of technologies of different natures. Among these technologies, the findings indicate the protocols, new procedures and knowledge that reach downwards to services. This notion is present since the federative normalizations which influence the field. As a result, you need to upgrade and adjust to not become obsolete. Thus, PE is presented in the discourses through the terms recycling, updating, and training, which refer to the preparation of professionals in face of technological innovations in health services.

To update is the adaptation to the present time and the modernization, to change from power to act or from virtuality to reality. Aristotle affirms that power and act are defined by their mutual relations, being power a capacity and act the complement, that which accomplishes it.¹ In this sense, it is inferred that the updating as a way of operating the PE represents the possibility to put into practice the inherent capacity of professionals. Thus, they are updated so that they can accomplish what is expected in the work process.

Foucault considers that updating is to see, at a given moment, the place where we are, seeking in repetitions and differences the relation of continuity or rupture. It is to diagnose the present to see in it the place where we are and to establish what is constituted, in the present, in its repetitions and differences, present-repetition, present-differences.¹

In the sense of updating, in the excerpts, it can be said that the professionals see the update through courses and training as a way to break with the repetitions of actions that believe to be right, recognizing differences between what is established in the courses and current trainings and between what they do and the knowledge that is understood as the current truth. That is, to find in the present what is and what is not more or find in the present what they are and what they are no more. However, this current truth, observed by chronology, can function as a contingency of the present, disrupting it as a historical process.

Then, the updating should be applicable in the confrontation between the present (difficulties and problems that the professionals perceive in their daily life) and the coming to be. However, daily life at BHU presents a hierarchical and heterogenized demand for types, meanings and importance of problems and needs, which are not always demanded from the trainers, to guide the process of PE. Often, the update comes from the other hierarchical levels and reach the professionals without problematization.

In reference to hierarchization, this is an organic part of daily life, in which its priorities are established according to the needs of each one. Therefore, everyday life is also heterogeneous.⁶ In the context of the basic unit analyzed, professionals experience dilemmas regarding the needs subjectivated by them and those demanded by the higher management levels. Villa states that the discussion of the organization of primary health care has been made based on the notion that managers have of work, without being able to glimpse the difficulties and rationality that govern the practice of other workers in everyday reality.¹²

In this sense, the findings demonstrate the professionals' dissatisfaction, which indicates that the PE movements prioritize the learning for the technique, demanded by the superior management, leaving to be desired the reflexive processes that associate theory and practice, demand of the superior management and of the collective of workers. Thus, the institutional movements of PE, although they are called updating, do little to interrogate the present, in the sense of its repetition. Thus they seem not to be an actualization, but to be repeated in new ways of acts and actions already existing. In this direction, the institutional movements of PE contribute to the technical dimension, practice of daily action with the repetition that is peculiar to it, generating automatism and spontaneity.

The automatism is characteristic of economicism, with repetition of socially accepted attitudes. In this process, the actions that allow us to be faster and shorter in the course of everyday life are modulated, when time and effort falls short of the necessary and expected, leading to the practical use of things. Spontaneity refers to the non-thought or planned, with attitudes as a result of that specific moment, without considering the future consequences, being worth the here and now.⁶ The findings allow the understanding that some PE strategy contributes to generate automatism and spontaneity, while others take from the comfort zone, discommode. This metaphor, to leave the comfort zone, means the discomfort of the position in which the subjects are, seeking the transformation in the daily life.

Accommodating is feeling comfortable in a given situation. Therefore, it is assumed that discommoding is to make uncomfortable, to remove from the place that is comfortable for you. Everyday action tends to a process of repetition which, once learned and learned, becomes comfortable. Repetitions are part of daily life, as a product of assimilation of social relations, which contribute to everyday life, whose learning is always in a group.⁶ In this direction, discommoding contributes to the non-quotidian, the situation in which men use their subjectivities, thinking beyond themselves, and incorporate the collective as a focus of reflection and action.

In this process, the new situations confront the private man, who seeks in his subjectivity the elements of genericity, thinking beyond himself, which gives him out of the daily life and returning to it modifying this same daily life. In this sense, development is created which goes beyond itself, since it involves the collective to which the subjects belong.¹³

The new situations make the subject move through spaces and diverse experiences, and can then be activated for the widening of the gaze and for the discommoding. The subject being unmotivated, that is, being uncomfortable in the place that is due to him, from the understanding that reality is complex and changeable, gives opportunity for his own growth and of his environment.

However, one must be aware that, given the technological advances, the pragmatism and spontaneity observed in some findings are not considered, when professionals associate PE with what one learns to put into practice at work. Thus, they run the risk of acting in an immediate manner, without problematizing and relating knowledge to the reality that surrounds them.

Science, being transformed into technology for production, becomes the pragmatism present in everyday life, in response to practical functions, are part and give mobility of action in the daily routine, characterizing daily life by the immediacy and spontaneity, in a system of mediations that unfold according to the characteristics given in the social, economic and cultural spaces.¹³

This pragmatism and spontaneity end up limiting the human-particular, which can sometimes pass between him and the generic human, that is, objectivation in and for himself, from the thought of preservation in the daily to the transformation of himself. But for this, in addition to working as a mediator, other mediators are necessary for the awakening of creativity and processes of change.⁶ In this sense, continuing education can be considered as a mediator of change, enabling human growth to deal with the world, reinterpreting reality, in a constant movement in permanent cycles.⁴

Every human being needs to survive in their daily life and, for this, they appropriate habits and customs, but in the experiences that life gives them, they often need to seek outside the particular world answers that are not given to them.⁶ Therefore, by getting in touch with the new, it will provide them with new experiences and maturity and, when they return to their daily life, brings with them new ways of seeing it, re-signifying it. This movement leads to the growth which takes place throughout all life, as it is sought to learn outside the particularity of survival.

The findings also show that the alignment of theory to practice in the daily life of BHU is valued, appearing as a side of the PE that allows the less objective and motivating development for a transforming praxis, when questioning the practice for the practice, which does not provide development in the daily service and work in health.

The theory is a non-everyday form of thought that contributes to human development, but this theory can remain immersed in daily life, not representing development for the collective.¹³ In this process, man can be consumed in fragmentation in his social roles and live by stereotyped form, with assimilation of the dominant norms, in particularity and in a conformist form, assigning to another his responsibility.

The fragmentation of the offer of courses by categories or by thematic can constitute and strengthen spaces of disciplinary hegemony, interfering in the microssocial relations, between the professions, in the production of the work and attention to the health. Thus, this way of organizing the PE is contradictory to the assumptions of multi-professionality and interdisciplinarity. In this sense, when thinking about the everyday and the needs of an interdisciplinary field, the discourses signal negative evaluations to the compartmentalized way, indicating the valuation of the learning from the collective ones, in continuous processes.

The construction of solidarity spaces provides awareness of the incompleteness and uncertainties, allowing the idea that continuing education should be a continuing process that emerges as a space for the reinvention of the subjects.¹

Continuing or lifelong learning carries the view that man is an unfinished being and to survive in an evolving world he needs to learn continuously. In this process, institutionalized education is not the only learning space, but all the moments of life in society, but all the spaces where there is the sharing of everyday knowledge.¹⁴

In this sense, it is considered that PE in the health sector can cause processes of change, in the different spaces, in a social practice that should include workers and users.¹⁵ Thus, the health service in the BHU is a potential space for education.

FINAL CONSIDERATIONS

The present study sought to analyze the discourses about continuing education in the daily life of a BHU. It was identified that there are several notions of PE, influenced by formulations in different contexts, from which emerges words with diverse cultural meanings, which inform the collectivization of discourse.

In the findings about the practice of PE as recycling, updating and discommoding and its correlation with the repercussions in the assistance model, became evidenced that the discomfort provides action and reflection, therefore, leading to positive changes in attention to users. However, recycling and updating constitute a need for the professional's adjustment in relation to the norms, protocols and directives of hierarchical levels of management. In this way, it provides adequacy to the technologies, without necessarily provoking changes in the attention model.

By valuing courses and trainings, the participants attribute to the institution the responsibility for the offer and institutionalization of the continuing education in an interdiscourse of the Ministry of Health and City Hall. However, they recognize and value PE in daily life as a social practice capable of providing transformations in the work processes and attention to users. In this direction, as implications for the practice, it is recommended to broaden the discussion about daily power with professionals, in order to activate the recognition and valuation of PE strategies as an instrument of change in social practices.

The limitations of this study are related to the research design in the strategy that adopted a single service as a scenario, which does not allow generalizations of its findings, despite its intensity and completeness. We must also consider the need for further research to understand the occurrence of continuing education and its transformations over time, as well as the external institutional discourses and their relationship in the daily life of BHU.

• FINANCIAL SUPPORT
  Permanent education in health and the ways of thinking and doing management, attention,Formation and participation in and for SUS - Process APQ 03466-14, financed by FAPEMIG.

REFERENCES

• ¹
  Figueiredo EBL, Silva APA, Abrahão AL, Cordeiro BC, Fonseca IA, Gouvêa MV. Efeito pororoca na educação permanente em saúde: sobre a interação pesquisa-trabalho. Rev Bras Enferm [Internet]. 2018; [cited 2018 Aug 23]; 71(Suppl. 4):1768-73. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672018001001768&lng=pt
  » http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672018001001768&lng=pt
• ²
  Bomfim ES, Oliveira BG, Rosa RS, Almeida MVG, Silva SS, Araujo IB. Educação permanente no cotidiano das equipes de saúde da família: utopia, intenção ou realidade? Rev Pesq Cuid Online [Internet]. 2017 Apr/Jun; [cited 2018 Aug 23]; 9(2):526-35. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/5464
  » http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/5464
• ³
  Moraes KG, Dytz JLG. Política de educação permanente em saúde: análise de sua implementação. ABCS Health Sci [Internet]. 2015; [cited 2018 Jun 1] 40(3):263-9. Available from: https://www.portalnepas.org.br/abcshs/article/view/806
  » https://www.portalnepas.org.br/abcshs/article/view/806
• ⁴
  Campos KFC, Sena RR, Silva KL. Permanent professional education in healthcare services. Esc Anna Nery [Internet]. 2017; [cited 2018 May 1]; 4(21):e20160317. Available from: http://www.scielo.br/pdf/ean/v21n4/pt_1414-8145-ean-2177-9465-EAN-2016-0317.pdf DOI: 10.1590/2177-9465-EAN-2016-0317
  » https://doi.org/10.1590/2177-9465-EAN-2016-0317» http://www.scielo.br/pdf/ean/v21n4/pt_1414-8145-ean-2177-9465-EAN-2016-0317.pdf
• ⁵
  Garzon AMM, Silva KL, Marques RC. La pedagogía crítica liberadora de Paulo Freire en la producción científica de la enfermería 1990-2017. Rev Bras Enferm [Internet]. 2018; [cited 2018 Aug 20]; 71(Suppl. 4):1751-8. Available from: http://www.scielo.br/scielo.php?pid=S0034-71672018001001751&script=sci_arttext&tlng=en
  » http://www.scielo.br/scielo.php?pid=S0034-71672018001001751&script=sci_arttext&tlng=en
• ⁶
  Mafra JF. O cotidiano e as necessidades da vida individual: uma aproximação da antropologia de Agnes Heller. Educ Ling [Internet]. 2010 Jan/Jun; [cited 2018 Aug 20]; 13(21):226-44. Available from: https://www.metodista.br/revistas/revistas-ims/index.php/EL/article/view/2019
  » https://www.metodista.br/revistas/revistas-ims/index.php/EL/article/view/2019
• ⁷
  Resende VM, Ramalho VCVS. Análise de discurso crítica, do modelo tridimensional à articulação entre práticas: implicações teórico-metodológicas. Ling (Dis)curso-LemD, Tubarão [Internet]. 2004 Jul/Dec; [cited 2018 Aug 20]; 5(1):185-207. Available from: http://www.portaldeperiodicos.unisul.br/index.php/Linguagem_Discurso/article/view/307
  » http://www.portaldeperiodicos.unisul.br/index.php/Linguagem_Discurso/article/view/307
• ⁸
  Medeiros Z. Genres, multimodality, and literacies. Rev Bras Linguist Apl [Internet]. 2014 Jul/Sep; [cited 2018 Aug 6]; 14(3):581-612. Available from: http://www.scielo.br/scielo.php?pid=S1984-63982014000300005&script=sci_arttext
  » http://www.scielo.br/scielo.php?pid=S1984-63982014000300005&script=sci_arttext
• ⁹
  Araujo GM, Reisdorfer N, Silva LAA, Soder RM, Santos AM. Segurança do usuário: cuidados com o processamento de artigos críticos na atenção básica. Rev Enferm UFPE On Line [Internet]. 2017 Oct; [cited 2018 Aug 6]; 11(Supl. 10):4096-102. Available from: http://pesquisa.bvsalud.org/portal/resource/pt/bde-33200
  » http://pesquisa.bvsalud.org/portal/resource/pt/bde-33200
• ¹⁰
  Mendonça AWPC, Xavier LN, Breglia VLA, Chaves MW, Oliveira MTC, Lima CM, et al. Pragmatismo e desenvolvimentismo no pensamento educacional brasileiro dos anos de 1950/1960. Rev Bras Educ [Internet]. 2006 Jan/Abr; [cited 2018 Aug 6]; 11(31):96-199. Available from: http://www.scielo.br/pdf/rbedu/v11n31/a08v11n31.pdf
  » http://www.scielo.br/pdf/rbedu/v11n31/a08v11n31.pdf
• ¹¹
  Marques CMS, Egry EY. The competencies of health professionals and the ministerial policies. Rev Esc Enferm USP [Internet]. 2011; [cited 2018 Aug 20]; 45(1):187-93. Available from: http://www.scielo.br/pdf/reeusp/v45n1/26.pdf
  » http://www.scielo.br/pdf/reeusp/v45n1/26.pdf
• ¹²
  Villa EA, Aranha AVS, Silva LLT, Flôr CR. Power relations in the work of Family Health Strategy. Saúde Debate [Internet]. 2015 Oct/Dec; [cited 2018 May 1]; 39(107):1044-52. Available from: http://www.scielo.br/pdf/sdeb/v39n107/0103-1104-sdeb-39-107-01044.pdf
  » http://www.scielo.br/pdf/sdeb/v39n107/0103-1104-sdeb-39-107-01044.pdf
• ¹³
  Veroneze RT. Agnes Heller: daily life and individuality - an experience in the classroom. Textos Contextos (Porto Alegre) [Internet]. 2012 Jan/Jun; [cited 2018 Aug 22]; 12(1):162-72. Available from: revistaseletronicas.pucrs.br/ojs/index.php/fass/article/download/14217/9626
  » revistaseletronicas.pucrs.br/ojs/index.php/fass/article/download/14217/9626
• ¹⁴
  Costa MAR, Souza VS, Teston EF, Spigolon DN, Matsuda LM. Educação permanente em saúde: a concepção freireana como subsídio à gestão do cuidado. Rev Fund Care Online [Internet] 2018 Apr/Jun; [cited 2018 Aug 20]; 10(2):558-64. Available from: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/6368
  » http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/6368
• ¹⁵
  Silva KL, Matos JAV, França BD. The construction of continuing education in the process of health work in the state of Minas Gerais, Brazil. Esc Anna Nery [Internet]. 2017; [cited 2018 Aug 6]; 21(4):e20170060. Available from: www.scielo.br/pdf/ean/v21n4/pt_1414-8145-ean-2177-9465-EAN-2017-0060.pdf
  » www.scielo.br/pdf/ean/v21n4/pt_1414-8145-ean-2177-9465-EAN-2017-0060.pdf

Publication Dates

• Publication in this collection
  29 Oct 2018
• Date of issue
  2018

History

• Received
  07 June 2018
• Accepted
  25 Aug 2018